MEDICARE: JOHN G. FATSE, DMD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	007150	CT

General Provider Information

NPI Number	:	1023235827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN G. FATSE, DMD, LLC

Provider Business Mailing Address
First Line	:	324 ELM ST
Second Line	:	SUITE 202A
City	:	MONROE
State	:	CT
Zip	:	06468-2280
Country	:	US
Telephone Number	:	203-268-5051
Fax Number	:	203-268-7988

Provider Business Practice Location Address
First Line	:	324 ELM ST
Second Line	:	SUITE 202A
City	:	MONROE
State	:	CT
Zip	:	06468-2280
Country	:	US
Telephone Number	:	203-268-5051
Fax Number	:	203-268-7988

Authorized Official
Title or Position	:	OWNER, DENTIST
Name	:	DR. JOHN G FATSE
Credential	:	D.M.D.
Telephone Number	:	203-268-5051

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	08/22/2020

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